1. Introduction to Health Literacy UAB GEC Faculty Scholars Program July 26, 2013 Gabriel Rios, MLIS Health Literacy Consultant

2. Objectives Define health literacy Discuss how low health literacy impacts health Identify tools to assess health literacy levels Practice interventions for clients with low health literacy Discuss strategies and resources for improving health literacy

3. Teaching Tool: LEP Exercise

4. Define health literacy

5. What is Health Literacy? IOM – “Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” NLM - “Health literacy is the ability to read, understand, and act on health information.” 5

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7. Basic information about a colonoscopy, as perceived…

8. National Assessment of Adult Literacy (NAAL) 2003 Most up to date portrait of literacy in U.S. Scored on 4 levels Lowest 2 levels cannot: o Use a bus schedule or bar graph o Explain the difference in two types of employee benefits o Write a simple letter explaining an error on a bill National Center for Education Statistics, U.S. Department of Education

9. 78 Million Adults have Basic or Below Basic Literacy

10. Trends in Literacy Over Time A comparison of National Adult Literacy Survey (1992) and the National Assessment of Adult Literacy (2003) o The percentage of adults with below basic levels of literacy remained constant o The percentage of adults with proficient levels of literacy has declined

11. Types of illiteracy Functional illiteracy Sensory/physical illiteracy o Blindness o Deafness o Neurological impairments Cultural/language illiteracy Psychological illiteracy Computational literacy

12. Health Literacy in Older Adults

13. Barriers to Self Care Economic Language - limited English proficiency Healthcare system - insurance, appointment, signage Activities of daily living Access to information Provider/patient Communication Other barriers?

14. Why Is Health Literacy Important? Health literacy is important because it affects a person’s ability to: o Navigate the healthcare system o Share personal and health information with providers o Engage in self-care and chronic disease management o Adopt health-promoting behaviors, such as exercising and eating a healthy diet o Act on health-related news and announcements (media literacy) 14

15. Review - What is Health Literacy? Not only reading skill….BUT ALSO Writing Speaking Listening Numeracy Cultural and Conceptual knowledge

16. Discuss how low health literacy impacts health

17. Limited Health Literacy Leads to… Underutilization of services Poor understanding of health Increased hospitalizations Poor health outcomes Increased healthcare costs Increased medication errors

18. Increased Medication Errors Labels are seemingly simple but not necessarily clear. Mistakes are more likely the more medication a patient takes. Ability to read a Rx label does not guarantee ability to understand and act.

19. Medication Errors - Industry Standards Inconsistent labeling Branding trumps all Confusing numbers Poor color combinations Curved shape is hard to read Tiny type Older Adults fill 30 Rx/year, see 8 clinicians

20. Medication Errors - ClearRx Easy I.D. Code Red Information hierarchy Upside down to save paper Green is for Grandma An info card that’s hard to lose Take “daily” Clear warnings.

21. Medication Errors - Instructions

23. Navigational Errors - Signage Some people become confused about whether this entry was intended for ambulances or for patients The use of visuals clarify the message Contrast in color makes it easy to read Try to be consistent when hanging signs Ambulatory Entrance Hospital XYZ Ambulatory Entrance

24. Teaching Tool: Navigational Errors What are the tasks a patient needs to accomplish in a health care visit? Diabetes patient o Pre-visit o Visit o Post-visit

25. Teaching Tool: Health Care Navigation and Self-Care Tasks

26. What can we do? Raise awareness among providers Develop easier to read materials Improve communication skills Practice-redesign Literacy training / adult education

27. Identify tools to assess health literacy levels

28. Less effective methods of health literacy assessment Years of education (except at extremes) Race Income Age Reliance on self-disclosure

29. Methods of Assessing Health Literacy Informal Word pronunciation tests Cloze method Newest Vital Sign Davis TC, Kennan E, Gazmararian J, Williams MV. Literacy Testing in Health Care Research. Understanding Health Literacy: Implications for Medicine and Public Health. Chicago: AMA Press; 2004.

30. Identify Low Health Literacy: (Informal) Fills out intake forms incompletely o “I forgot my glasses” o “Let me bring this home so I can discuss it with my children.” o “My hand hurts too much to write” Misspelling many words Gets angry about forms Identifies medication by looking at pill rather than reading the label Other means? Weiss BD. Health literacy: a manual for clinicians. 2003

31. Teaching Tool: Newest Vital Sign Exercise

32. Newest Vital Sign

33. Word Pronunciation Tests Rapid Estimate of Adult Literacy in Medicine (REALM) o Word recognition and pronunciation Wide Range Achievement Test (WRAT) o Word recognition and pronunciation

34. Cloze Method Test of Functional Health Literacy in Adults (TOFHLA) Allows students to "intelligently guess" and fill in missing words from a written passage. Tests reading comprehension using skills like: o Background knowledge o Context cues o Semantics o Syntax o General understanding of material o Grammar skills

35. Your doctor has sent you to have a _________ X-ray. a. stomach b. diabetes c. stitches d. germs You must have an ________ stomach when you come in for ___. a. asthma b. empty c. incest d. anemia a. is b. am c. if d. it TOFHLA (Cloze method) Available from: Peppercorn Books & Press Inc. (www.peppercornbooks.com)

36. Problems with Measuring Literacy Sensitive topic May offend some If it is seen as a “test” it can be threatening Patients hide low literacy Inappropriate labeling Time

37. Three Screening Questions “How often do you have someone help you read hospital materials?” “How confident are you filling out medical forms by yourself?” and “How often do you have problems learning about your medical condition because of difficulty understanding written information?” Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Family Medicine. 2004; 36(8)588–94.

38. Discuss strategies and resources for improving health literacy

39. Strategies: Providers and Staff Whole staff must be aware and sensitive Assess baseline understanding Explain things clearly using plain language Start with most important information first and limit new information Effectively encourage patients to ask questions Use teach-back to confirm understanding Provide useful educational materials Repeat important points

40. Understanding Clarify Assess Explain Teach back

41. Strategies: Clear Communication Assess baseline understanding Explain things clearly using plain language Emphasize 1-3 points Effectively encourage patients to ask questions Use teach-back to confirm understanding Write down important instructions Provide useful educational materials

42. Helpful phrases “I want you to explain to me how you will take your medication, so I can be sure I have explained everything correctly,” or “Please show me how you will use the asthma inhaler, so I can be sure I have given you clear instructions,” or “When you get home your spouse will ask you what the doctor said—what will you tell your spouse?” “We don’t always do a great job of explaining our care plan. Can you tell me in your words how you understand the plan?”

43. More on teach-back Do not ask a patient, “Do you understand?” Ask patients to explain or demonstrate Ask questions that begin with “how” and “what,” rather than closed-ended yes/no questions Organize information so that the most important points stand out and repeat this information Ensure agreement and understanding about the care plan. This is essential to achieving adherence

44. Teaching Tool: Plain Language Exercise

45. Resources: AMA Health Literacy Videos Health Literacy Toolkit from AMA Foundation o http://bit.ly/fZjvex http://bit.ly/fZjvex o http://www.youtube.com/watch?v=FlGDn1r2RwY http://www.youtube.com/watch?v=FlGDn1r2RwY

46. Resources: AHRQ Toolkit AHRQ Health Literacy Universal Precautions Toolkit o http://www.ahrq.gov/qual/literacy/ http://www.ahrq.gov/qual/literacy/ Quick start guide Path to improvement (6 steps to take) 20 Tools

48. Strategies: Standards JCAHO RI.01.01.03 “For communication to be effective, the information provided must be: o Complete o Accurate o Timely o Unambiguous o And understood by the patient.” Affordable Care Act: Health Literacy Implications National Action Plan to Improve Health Literacy o http://www.health.gov/communication/hlactionplan/ http://www.health.gov/communication/hlactionplan/ Introduction to Standard RI.01.01.03, CAMH Update 2, October 2009

49. Strategies: Educational Materials Good health information is often hard to come by Most health information written at too high of a reading level Few health care systems have comprehensively integrated educational materials in their overall care plans

50. Strategies: Use Patient-Friendly Educational Materials Simple wording, short sentences o 4th-6th grade level Picture based Focus only on key points Emphasize patient concerns o What the patient may experience o What the patient should do Minimize information about disease statistics, anatomy, and physiology Be sensitive to cultural preferences

51. Resources: NIH Senior Health http://nihseniorhealth.gov Health information for older adults Partnership of National Institute on Aging and National Library of Medicine Information comes from National Institutes of Health Older Adult-friendly features (large text, sound, contrast) Information in bite-sized pieces

52. Resources: MedlinePlus http://www.medlineplus.gov Launched in 1998 Free Health information for patients and consumers Quality filtered credible sources Spanish language Low literacy materials

53. Review Define health literacy Discuss how low health literacy impacts health Identify tools to assess health literacy levels Practice interventions for clients with low health literacy Discuss strategies and resources for improving health literacy

54. Resources AMA Foundation Health Literacy Toolkit o http://bit.ly/fZjvex http://bit.ly/fZjvex AHRQ Health Literacy Universal Precautions Toolkit o http://www.ahrq.gov/qual/literacy/ http://www.ahrq.gov/qual/literacy/ AHRQ Health Literacy Interventions and Outcomes (SR) o http://www.ahrq.gov/clinic/epcsums/litupsum.htm http://www.ahrq.gov/clinic/epcsums/litupsum.htm MedlinePlus o http://www.medlineplus.gov http://www.medlineplus.gov

55. Questions? Gabriel R. Rios grios@uab.edu